Expansion of Carelon Medical Benefits Management, Inc. programs

At a glance:

• Carelon Medical Benefits Management will expand programs to include cardiovascular, musculoskeletal, and surgical reviews beginning March 1, 2025.
• Additional outpatient UM will include transportation, fertility, and various other therapeutic and monitoring services.
• Providers must obtain online pre‑service reviews for certain procedures starting February 24, 2025.

As a reminder, effective March 1, 2025, Carelon Medical Benefits Management will expand multiple programs to perform medical necessity reviews for additional procedures for our members. Carelon Medical Benefits Management works to improve healthcare quality and manage costs for today’s most complex and prevalent tests and treatments, helping promote appropriate, safe, and affordable care.

The continued migration will expand clinical appropriateness reviews for procedures related to the following existing Carelon Medical Benefits Management programs: cardiovascular, musculoskeletal, and surgical. In addition, some codes will migrate into a new Carelon Medical Benefits Management solution — additional outpatient UM that will include some transportation (including ambulance) and fertility procedures, as set forth below. Transportation may include emergency post‑service reviews.

Our Clinical UM Guidelines and Medical Policies (also known as coverage guidelines in Virginia) for medical necessity review are listed in the table below. Carelon Medical Benefits Management will begin accepting prior authorization requests on February 24, 2025, for dates of service on or after March 1, 2025.

Members included in the new program

Updates to Carelon Medical Benefits Management programs apply to select local fully insured members and members covered under self‑insured (ASO) benefit plans with services medically managed by Carelon Medical Benefits Management. This notice does not apply to certain HMO, BlueCard®, Medicare Advantage, Medicaid, Medicare supplemental, or Federal Employee Program® (FEP^®) plans. For more information, please contact the phone number on the back of the member ID card. 

Pre‑service review requirements

For procedures scheduled to begin on or after March 1, 2025, all care providers must contact Carelon Medical Benefits Management to obtain a pre‑service review for the services, including, but not limited to, the following non‑emergency modalities. Please refer to the Clinical Guidelines at Anthem.com > Providers > Provider Resources > Policies, Guidelines & Manuals for complete code lists.

Note: All codes will be reviewed for medical necessity for the requested service and not for site of care.

To determine if prior authorization is needed for a member on or after March 1, 2025, contact the Provider Services phone number on the back of the member’s ID card for benefit information. Care providers using the Interactive Care Reviewer (ICR) tool on http://Availity.com/ to pre‑certify an outpatient procedure will receive a message referring the provider to Carelon Medical Benefits Management. (Note: ICR cannot accept prior authorization requests for services administered by Carelon Medical Benefits Management.)

Care providers should continue to submit pre‑service review requests to Carelon Medical Benefits Management using the convenient online service provided on the Carelon Medical Benefits Management provider website. The website is available 24 hours a day, seven days a week, and processes requests in real time using Clinical Criteria. Go to https://www.providerportal.com/ to register.

For more information

For resources to help your practice get started with the cardiology, musculoskeletal, radiology, sleep, surgical procedures, and radiation oncology programs, visit:

Cardiovascular Solution | Carelon Insights

Radiology Solution | Carelon Insights

Sleep Solution | Sleep Healthcare | Carelon Insights

Surgical Procedures Solution | Carelon Insights

Radiation Oncology Solution | Carelon Insights

Additional Outpatient Utilization Management

Sign up at provider training for provider training for the additional outpatient UM:

• Wednesday, February 5, 2025, at 12 p.m. ET/11 a.m. CT
• Wednesday, February 12, 2025, at 12 p.m. ET/11 a.m. CT
• Friday, February 21, 2025, at 11 a.m. ET/10 a.m. CT
• Wednesday, February 26, 2025, at 12 p.m. ET/11 a.m. CT
• Wednesday, March 5, 2025, at 12 p.m. ET/11 a.m. CT

Our website, Anthem.com, provides information and tools such as order entry checklists, Clinical Guidelines, and FAQ. You can also contact your provider relationship management representative if you have any questions.

Through genuine collaboration, we can simplify access to care and help you deliver high‑quality, equitable healthcare.